Value in care continuity

AUSTRALIA’S health system has everything to gain by enhancing continuity of care for patients, according to experts commenting on a study that reveals the link between the use of medical procedures and levels of care continuity.

Professor James Dunbar, from the Population Health Strategic Research Centre at Deakin University, told MJA InSight that the health system “is stretched to the max, so it makes sense to strip out the waste and cut down on all the inappropriate testing and treatment”.

“But unless you are the one holding the chequebook, you’re not going to be able to change anything, because remuneration is key”, Professor Dunbar said.

He was commenting on a study published last week in JAMA Internal Medicine that examined the association between care continuity and the use of potentially unnecessary procedures. (1)

The authors used a random sample of 5% of fee-for-service patients aged over 65 years insured with Medicare in the US in 2008. Continuity was evaluated using the Bice–Boxerman continuity of care index, and overuse was measured using a previously validated set of 19 potentially overused procedures.

They found that 14.7% of the 1 208 250 patients in the sample received at least one potentially overused procedure during the calendar year. For each 0.1 increase in the continuity score, patients had 0.93 times the odds of receiving overused procedures than those with lower scores.

“Our research suggests that higher levels of continuity are associated with lower use of certain commonly overused therapeutic procedures and increased use of other indicators of overuse”, the authors wrote.

They said it would be “critical to monitor the link between continuity and overuse over time”, saying it was possible that efforts to improve continuity could reduce some forms of waste in the health care system while increasing others.

Brisbane GP Justin Coleman told MJA InSight he would “be surprised if there wasn’t a similar correlation between continuity of care and the use of medical procedures in Australia”.

Dr Coleman said enhanced continuity of care translated to better patient outcomes, and general practice was at the heart of this. “GPs are the gatekeepers; they coordinate care and can know when to shut the gate.”

However, he said a primary factor contributing to poor continuity of care was the trend of prescribing “just in case” medications to patients.

This was particularly prevalent in after-hours clinics, where a higher level of interventional treatments, such as antibiotics, was prescribed because the doctor was unsure if the patient would ever return to the clinic.

Dr Coleman said it was therefore critical to “improve communication between the different cogs of the health system, and ensure we always get adequate and timely hospital discharge summaries”.

An accompanying commentary on the JAMA Internal Medicine research said that current trends in training and organisation were making it very difficult to preserve continuity as a core value of the “one doctor, one patient” model that once characterised medicine. (2)

Associate Professor Richard King, head of medicine at Monash Health and inaugural chair of the Choosing Wisely Australia Advisory Group, said Australia had been making efforts to restore continuity as a core value.

However, key issues that were still causing problems included the continued overuse of pathology, and the disjointed information exchanges between hospital locations.

“In Melbourne, for example, there is gap between the acute care hospitals and rehab facilities.”

Professor King said the ongoing overuse of medicine was an example of the importance of the Choosing Wisely initiative. (3)

In a statement to MJA InSight, Dr Frank Jones, the president of the Royal Australian College of General Practitioners (RACGP), said the college recognised the benefits of patients receiving continuous care from a GP, and was proposing a system of voluntary patient enrolment as part of its Vision for a Sustainable Health System. (4)

“When patients voluntarily enrol with a specific practice and preferred GP, their GP is able to refer to detailed medical records and ensure patients are not subjected to tests and treatments they do not need.

“This will give patients a medical home, and ensure care is patient centred, comprehensive and coordinated”, Dr Jones said.

1. JAMA Internal Medicine 2015; Online 18 May
2. JAMA Internal Medicine 2015; Online 18 May
3. Choosing Wisely Australia
4. RACGP vision for a sustainable health system

(Photo: Monkey Business Images / Shutterstock)